Urolithiasis. Ali Kasraeian, MD, FACS Kasraeian Urology Advanced Laparoscopic, Robotic & Minimally Invasive Urologic Surgery

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1 Urolithiasis Ali Kasraeian, MD, FACS Kasraeian Urology Advanced Laparoscopic, Robotic & Minimally Invasive Urologic Surgery

2 Urolithiasis: Why should we care? Affects 5% of US men and women Men twice as likely to develop calculi A metabolic etiology can be found in 97% of people with stone disease Recurrent calculi can be prevented in most patients Without treatment, recurrence rate approaches 50% at 10 years Estimated cost of ~$2 billion per year

3 Urolithiasis: types of calcluli Calcium Oxalate (70%) Calcium Phosphate (5-10%) Uric Acid (10%, Urine ph < 5.5) Struvite (15-20%) Cystine (1%)

4 Urolithiasis: pathophysiology Renal Calculi develop from microscopic crystals in the Loop of Henle, distal tubule, or collecting duct. Stone formation depends on urinary volume, concentrations of ions (Calcium, Phosphate, oxalate, sodium, and uric acid), concentrations of natural inhibitors of calculi (Citrate, Magnesium, Tamm-Horsfall mucoproteins, bikunin), and urinary ph. Low Urine Volume, High Ion Levels and Low Citrate Levels favor Calculus Formation

5 Urolithiasis: Risk Factors Low urine volume (allows stone constituents to supersaturate) Excess dietary meat (creates acidic urine, depletes citrate, hyperuricosuria) Excess dietary oxalate Excess dietary sodium (promotes hyerpcalciuria) Family history (genetic predisposition) Insulin resistance (alters urine ph, ammonia mishandling) Bowel Disease (low urine volume, acidic urine depletes citrate, hyperoxaluria) Gout ( hyperuricosuria) Obesity (hypercalciuria) Primary Hyperparathyroidism (hyerpcalciuria) Prolonged immobilization (bone turnover creates hypercalciuria) Renal Tubular Acidosis - Type 1 (alkaline urine promotes CaPhossphate supersaturation, loss of citrate)

6 Urolithiasis: General Recommendations Increase Hydration (Urine Volume > 2 L / day) Low Animal Fat Diet Low protein Diet Low Salt Diet

7 Urolithiasis: presentation Pain (Renal Colic) Nausea / Vomiting Fevers/Chills LUTS Anorexia

8 Urolithiasis: Work up History & Physical Labs: CBC, BMP, UA, UCx Imaging

9 Urolithiasis: diagnosis KUB IVP US NCCT

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21 You Have a stone: What next?

22 Urolithiasis: urologic consultation Unyielding, uncontrolled pain Nausea/vomiting Stone > 5mm Fever, UTI Renal dysfunction, obstructive uropathy

23 Urolithiasis indications for admission and intervention Complete or High Grade Obstruction Any Degree of Bilateral Urinary Obstruction Solitary Kidney with Any Degree of Urinary Obstruction Any Degree of Urinary Obstruction with Fever or Leukocytosis Any Degree of Urinary Obstruction with Azotemia / Renal dysfunction Obstruction in Diabetic or Immunocompromised Patients Inability to Tolerate PO Intake due to N/V Severe Pain NOT controlled with oral Analgesics Stone that is Unlikely to Pass due to SIZE and/or LOCATION

24 Urolithiasis Likelihood of spontaneous passage based on size & location 1 mm stone = 90% (~ 8 days) 5 mm stone = 56% (~22 days) 9 mm stone = 3% 90% of stone 5 mm or less will pass within 40 days smaller and more distal stones more likely to pass

25 Urolithiasis: Management options Trial of Passage Medical expulsive therapy Urinary diversion ureteral stent percutaneous nephrostomy tube Extracorporeal Shock Wave Lithotripsy (ESWL) Endoscopic management Ureteroscopy (URS) Percutaneous Nephrolithotomy (PCNL) Open stone surgery

26 Urolithiasis: Management options medical expulsive therapy Alpha-1 receptors are located in the human ureter, especially the distal ureter. Alpha-blockers (i.e., Flomax or Tamsulosin) increase expulsion rates of distal ureteral stones decrease time to expulsion decrease need for analgesia during stone passage. Alpha-blockers promote stone passage in patients receiving shock wave lithotripsy may be able to relieve ureteral stent-related symptoms In the appropriate clinical scenario, the use of α-blockers is recommended in the conservative management of distal ureteral stones.

27 Urolithiasis: Management options medical expulsive therapy Reviews in Urology 2006

28 Urolithiasis: urinary diversion Ureteral stent

29 Urolithiasis: urinary diversion Percutaneous Nephrostomy tube

30 Urolithiasis: Management options eswl

31 Urolithiasis: Management options Management depends on stone location and size

32 Urolithiasis: Management options Management depends on stone location and size

33 Urolithiasis: Management options Ureteroscopic management Ureteroscopy Stone basket manipulation Laser lithotripsy +/- ureteral stent

34 Urolithiasis: Management options PCNL

35 Urolithiasis: Management options Management depends on stone location and size

36 Urolithiasis: Management options Open stone surgery

37 Urolithiasis: prevention After initial stone episode has resolved, patient should be counseled about preventing recurrences. History & Physical Age of onset, frequency and number of previous stones, previous interventions Evaluation of risk factors and dietary habits Prior stone composition (stone analysis) Laboratory studies BMP, calcium, phosphate, uric acid, intact parathyroid hormone (as indicated) 24 hour urine collection Follow-up Imaging (KUB, NCCT)

38 Urolithiasis: prevention

39 Urolithiasis: Why should we care? Affects 5% of US men and women Men twice as likely to develop calculi A metabolic etiology can be found in 97% of people with stone disease Recurrent calculi can be prevented in most patients Without treatment, recurrence rate approaches 50% at 10 years Estimated cost of ~$2 billion per year

40 Thank you Ali Kasraeian, MD, FACS Kasraeian Urology The Conversation: A Radio Show wokv FM / 690 AM Saturday 5 pm AliKasraeian@KasraeianUrology.com TheConversationJax.com Facebook: the conversation jax